Pancreas

Question 1

Surgery for chronic pancreatitis

Answer 1

> 6mm dilated. Will likely respond to surgery. Can do

puestow: roux-en-y pancreaticojejunostomy

Frey: subtotal ventral head resection (core out a chunk of the head) + pancreaticojejunostomy-

Beger: duo preserving panc head rxn -> you have two pancreatico-J’s here. One to the tail and one to the remainder of the head

Question 2

What % of ppl with peripancreatic fluid collection will develop pseudocyst?

• what % will become symptomatic?
• what is the spontaneous regression rate?
• what % will become infected?

Answer 2

• about 5-15% will develop psuedocyst
• about half will develop symptoms
• 70% spontaneous regression rate
• about 1/3 will become infected

Question 3

When doing a cystgastrostomy the anastomosis should be interrupted or running?

Answer 3

Interrupted full thickness. If running suture, may become loose when edema dies down

Question 4

What is the T staging for pancreatic cancer?

Answer 4

T1: <2cmT2: >2cmT3: extension beyond pancreasT4: tumor involves celiac axis or sma

Question 5

Patient with chronic pancreatitis. What’s the order of workup after CT showing dilated PD?

Answer 5

If any abnormality seen on CT -> endoscopic ultrasound to rule out mass

If no endoscopic ultrasound -> ERCP .
If proximal stricture then dilate + stent.

not MRCP

Question 6

When doing a cystgastrostomy the anastomosis should be

partial thickness or full thickness?

running or interrupted?

Answer 6

Interrupted full thickness. If running suture, may become loose when edema dies down

Question 7

Most common genetic abnormality for pancreatic cancer

Answer 7

KRAS2 in more than 95% of pancreatic cancers

Question 8

Management of IMPN first based on what?

Answer 8

Communication to the duct (main duct and mixed type) -> resection

Branch duct:
<1cm: repeat CT annually
1-3cm: repeat CT in 6 mo. Then annually
>3cm: rxn to neg margin

Question 9

What is the definition of a pancreatic leak?

Answer 9

Drain amylase > 3x serum on POD #3

Question 10

How prevalent is pancreas divisum?

What is the treatment?

Answer 10

Up to 10% of population. More common in women in 3rd, 4th decade

ERCP, sphincterotomy/papillotomy of the minor papilla (Santorini)

Dorsal panc= body. In embryo, drained by Santorini into minor papilla

Ventral panc= head/neck. In embryo, drained by Wirsung into major papillaVentra

Question 11

Describe the step up approach for pancreatic necrosis

Answer 11

1) perc drainage
2) if no improvement in 72hrs -> second drainage
3) if no improvement in 72hrs -> video assisted retroperitoneal debridement with post-op lavage

Question 12

Describe the classification of fluid collections in acute pancreatitis

Answer 12

Necrosis -> acute necrotic collection -> 4 wks -> walled off necrosis

No necrosis -> acute peripancreatic collection -> 4 wks -> paeudocyst

Question 13

How much does smoking increase the risk for pancreatic cancer?

Answer 13

Smoking increases risk by ~75%Alcohol increases risk by 20-30%Chronic pancreatitis: 5-7% lifetime risk

Question 14

Dry mouth, eyes, elevated IgG4. Diagnosis?

Associated with what other syndrome?

Answer 14

Autoimmune pancreatitis

Male > female 2:1

Associated with antiphospholipid syndrome

Question 15

Surgical treatment option for hereditary pancreatitis?

Answer 15

Total pancreatectomy and auto islet transplantation

Question 16

Where do the ant/post superior pancreaticoduodenal arteries come from?

What about ant/post inferior pancreaticoduodenal arteries?

Where does the dorsal pancreatic artery come from?

Answer 16

Superior: from celiac -> GDA

Inferior: from branches of the SMA

Dorsal pancreatic: from splenic

Question 17

What can you use for metastatic or recurrent unresectable insulinomas?

Answer 17

Streptozotocin or

Diazoxide

Question 18

Pancreatic neuroendocrine tumor. Which one is mostly benign? Mostly malignant?

Answer 18

All are malignant and maybe metastatic at diagnosis except insulinomas.

Insulinomas: ~10% malig

Question 19

What is Verner-Morrison syndrome?

Answer 19

WDHA syndrome

Watery
Diarrhea
Hypokalemia
Achlorhydia

VIP, PPP, GIO secreting tumors
~50% malig. Most metastatic at diagnosis
Resection is possible. Streptozocin/diazoxide
Somatostatin

Question 20

Ransom criteria mortality prediction is more accurate for alcoholic or biliary pancreatitis?

Answer 20

EtOH

Question 21

What are the success rates for chronic pancreatitis surgery if the duct is dilated vs not?

What surgeries do you do if the duct is not dilated?

Answer 21

60-70% success rate if duct is dilated. Puestow

<50% success rate if the duct is not dilated. Resect them. Whipple, Beger, or Frey, or celiac plexus blockade

Beger: duodenum preserving panc head rxn. RNY panc head-J, panc tail-J. Two anastomoses

Frey: subtotal ventral head resection and drainage. CORE out the head and do RNY panc-J

Question 22

Difference in surgical treatment between communicating vs non-communicating pancreatic pseudocyst?

Answer 22

Communicating: always drain into jejunum. RNY cyst-jejunostomy

Non-communicating: RNY cyst jejunostomy, cyst-gastrostomy, cyst-duodenuostomy

Question 23

What’s the 5yr survival for resectable pancreatic cancer +/- neoadjuvant chemo?

Answer 23

Surgery alone: 18% With neoadjuvant: ~30%

Question 24

Which pancreatic lesions?

Immunohistochemical staining demonstrates nuclear localization of beta-catenin

Answer 24

Pseudopapillary neoplasm

Question 25

Which pancreatic lesion?

Ovarian stroma

Answer 25

Mucinous cystic neoplasm

Question 26

Which pancreatic lesion?

Fish mouth

Answer 26

IPMN produces mucin protruding through the ampulla

Question 27

Pancreatic lesion with chromogranin A?

Answer 27

Any pancreatic neuroendocrine tumor. ~10% will be chromogranin A (+)

Question 28

What does acid-Schiff stain stain?

Which pancreatic lesion?

Answer 28

Glycogen.

Serous cystic neoplasm

Question 29

Splenic artery is in what relationship to the pancreas?

Answer 29

Superior to the pancreas

Question 30

For IPMN which of the following feature should trigger an operation?

• presence of mucin in aspirate
• mural nodularity
• cyst fluid CEA > 200

Answer 30

Mural nodularity -> definite predictor of malignancy

Question 31

What is a worrisome CEA level from a pancreatic cyst?

Answer 31

> 192

Question 32

What is a worrisome/high risk duct size for pancreatic cyst?

Answer 32

5-9mm: worrisome

>10mm: high risk

Question 33

What is the gold standard for diagnosing chronic pancreatitis?

What is the first line test for the diagnosis of chronic pancreatitis?

Answer 33

Gold standard: biopsy for tissue analysis

First line: CT

Question 34

What % of necrotic pancreatic collection will become infected?

Answer 34

1/3

Question 35

What is the sensitivity of CT and ERCP for diagnosis of pancreatic cancer?

Answer 35

CT: 85%
ERCP: 90%

However ERCP is not routinely used due to the invasive nature. Only if CT can’t identify lesions for obstructive jaundice

Question 36

Which pancreatic enzyme clears the fastest in the course of pancreatitis?

Answer 36

Amylase clears in less than 48 hrs but a level > 150 in the first 72 hrs is a consistent finding

Lipase remains elevated for >96hrs

Question 37

Pancreatic polypeptide [stimulates/inhibits] pancreatic secretions

Answer 37

Inhibits actually

Question 38

What is the most sensitive test for chronic pancreatitis?

Answer 38

most sensitive: Postprandial pancreatic polypeptide hormone level

gold standard: tissue biopsy
first test: CT